on the part of both the providers and the IPA provides an impetus for this change. This step in Kotter’s change model functions to establish a rationale for swift action, which otherwise might be delayed. This might be the most important step in catalyzing a large scale or paradigm shift within an organization or more broadly, across an industry.
An urgent need for change is important to ensure that the required recommendations for best practices are put near the top of a, likely competitive, priority list. It is important to establish a sense of urgency in all relevant stakeholders including both the IPA central
1. Create a Sense of Urgency 2. Build a Coalition 3. Form a Strategic Vision and Initiatives 4. Enlist a Volunteer Army 5. Enable Action by Removing Barriers 6. Generate Short-term Wins 7. Sustain Acceleration 8. Institute Change
As such, the best practices selected for this study were inherently selected due to their ability to produce value for patients, providers, and payers alike. This means they are based on activities that produce improve health outcomes while simultaneously decreasing costs. Thus, the sense of urgency to move to value based best practices for both providers and IPAs should be supported by healthcare’s continued efforts to move from volume-to-value based care. Additionally, the move to a value-based healthcare system has exerted pressure on IPAs and their respective provider networks to move away from fee-for-service for delivering and reimbursing care. The sense of urgency that exists for providers and IPAs as a function of this movement will help to facilitate the adoption of best practices.
When organizations take on financial risk based on performance (this means organizations are at risk for expenses but also share in profits if money is saved), they are incentivized to operate as efficiently as possible. Interests are aligned with improving health outcomes and reducing unnecessary expenditures (e.g., shifting from inpatient to outpatient care when appropriate). These motivations fit nicely with implementing best practices that seek to improve health outcomes and reduce costs. With the adoption of increased risk models, providers, payers organizations, and IPAs may feel an increased sense of urgency to embrace best practices.
To further promote the idea of value-based care, I will author a series of three articles for America’s Physician Groups (APG), an association of physician groups and IPAs. The articles will be published in a newsletter which is distributed 3 times a year to approximately 9000, to 12,000 readers. The article will focus on why value-based care models contribute to better outcomes for patients (particularly for patients with complex diseases such as those discussed throughout this study) and increased value for IPA organizations. The articles will
utilize both evidence from this research study as well as highlight case studies of organizations that have successfully transitioned to a value-based environment.
The articles will also include content on best practice strategies with an email address that interested parties can reach out to be placed on a listserv. The listserv will be used to send out information to engaged participants regarding successful best-practice strategies in- between newsletters distributions, as well as to encourage them to submit their own
experiences which will be shared with others on the listserv.
In regards to further dissemination of the results in this study, I plan to share pertinent information with interested organization such as the Learning Action Network as well as attempt to publish the findings in relevant peer reviewed journals.
Build a coalition. The coalition is intended to be the guiding body executing the recommendations and may serve one of the most influential roles in driving industry-wide change. The coalition will include representatives from senior leadership (e.g., Chief
Executive Officers and Chief Medical Officers,) as well as individuals that are patient-facing (e.g., Directors of Case Management.) My goal in forming the coalition is to serve as a resource for other IPA organizations that are currently not engaging in best practices. I will attempt to recruit coalition members who have experience implementing best practices, and who are willing to share success and failures with other organizations.
I will also leverage existing coalitions, such as provider associations. One such organization is the aforementioned APG, which is composed of a variety of physician led medical groups that have a large concentration of IPAs. I will work with the associations to identify strategies to promote best care management practices. The coalition will then
continue to be a guiding force for implementing the changes in their respective organizations and among the IPA community.
To promote the formation and sustainment of these coalitions, I will be giving
lectures at APG’s general member meetings across the United States. The lectures will focus on the benefits of adopting best practices. The lectures will also describe the enormous value of learning from one another as IPA organizations to share experiences. At the end of each lecture, a list of interested participants may be collected. There are approximately 20-30 member meetings per year, therefore the opportunity to speak to potential members of this forming coalition is high.
Once a list of interested APG members is formed, it will be provided to APG regionally with a designated APG volunteer leader selected for each region. It will be
suggested to APG that they integrate best practice discussions as outlined in this dissertation into their existing regular meetings. Members of the coalition are encouraged to use the APG platform to share experiences and espouse the benefits of evidenced-based practices. This approach will lead to APG-supported learning collaboratives, which are groups of individuals that get together to enhance their understanding of a particular subject, skill, or task. A
learning collaborative, supported by APG, will help to increase understanding of how to implement best practices and serve as a support system for those with less experience in adopting best practice. Learning collaboratives are often used as a means to bring together different teams or organizations who will work together towards a common goal. Similarly, a learning collaborative can be used to integrate best practices into the existing health care system, particularly among IPA organizations. IPA organizations will be encouraged to progressively learn from each other about implementation challenges and facilitators, and
these learning opportunities will be presented through the coalition leaders at regular intervals.
Form a strategic vision and initiatives. This step entails ensuring that all members of the coalition can disseminate a clear and consistent vision of the changes to the IPA community. Kotter mentions the importance of linking vision to practical and concrete strategic actions as a critical component of this step.
I will encourage the coalition and the appropriate APG members to have
booths/displays at relevant events where additional information will be passed out regarding successful implementation strategies for best practices. I would also suggest that APGs arrange dinners with industry thought leaders, as well as expert panels discussing strategies to adopt best practices and working to communicate and disseminate the vision.
To link vision to concrete strategic steps, members of the coalitions implementing the recommendations in their respective organizations should be prepared to share their vision and path to success within the learning collaborative, as well as to discuss failures and specific actions leading to those outcomes. I will help support APG to encourage the
dissemination of these experiences among IPAs implementing the best practices through the learning collaborative and newsletters, as well as through a series of lectures.
Although the ultimate process may differ among individual IPAs, the overall vision should be shared among IPAs as a community and espoused through the work of the driving coalition. The coalition will form learning collaboratives with the specific goal of sharing strategies that have led to success. IPAs that are willing to try new implementation methods and share their short-term and long-term results with the wider community should lead the
well as broader strategic insight and support. I would also support APG in connecting with those who have been pioneers in these areas to gauge their interest in becoming leaders for the learning collaborative. This will help make the vision a reality by applying concrete steps to support organizations in practice.
Enlist a volunteer army. Any large-scale change requires a large number of individuals to execute it. The volunteer army represents the manpower necessary to carry through the needed changes and consists of individuals who have demonstrated the
willingness to implement the recommendations. The volunteer army will include IPAs that believe in implementation of best practices and are willing to advocate for the changes. The volunteer army differs from the coalition in that they help support and execute the decisions made by the coalition. Generally, the coalition will be composed by best practice experts, while the volunteer army could be any number of individuals (not necessarily experts or with prior experiences) interested in implementing best practices.
I have reached out to several participants in the key informant interviews who have been instrumental in implementing best practices at their respective organizations to see if they would be willing to share their experiences with the IPA community. The individuals who agree will act as the first members of the volunteer army (potentially also joining the leading coalition). I will encourage these individuals to share their experiences with the wider IPA community. For example, I will invite them to participate in an expert panel at the APG general membership meetings to discuss their path to success in implementing best practices within their organization. The expert panel will occur at the APG general membership meetings.
This volunteer army (and guiding coalition) will also be responsible for such tasks as arranging gatherings for the IPA community to learn from one another’s implementation attempts, enlisting additional IPAs to adopt best practices, and documenting and
disseminating further information regarding the application of these best practices nationally. The goal of the volunteer army is to create momentum required to start and sustain a
movement that allows other IPAs to more easily adopt the successes and avoid the failures of organizations that attempted best practice implementation.
Enable action by removing barriers. Every large-scale change effort will face barriers; this step in Kotter’s framework refers to removing these barriers to be as effective as possible in driving change. One barrier to implementation of best practices in the IPA
industry includes policy changes. For example, if value-based care does not continue to be supported by the primary payers (CMS), the lack of revenue may influence the ability of organizations to implement best practices. Another barrier is the lack of knowledge regarding how to successfully implement best practices in an IPA environment. The strategies to
remove such barriers will be supported by the first three recommendations (outlined in Chapter: 5 Discussion) which are tailored towards to mitigating against major barriers IPAs have come across in the implementation process.
Per the Readiness Recommendations (1 through 3), several characteristics of IPAs may make organizations more or less prepared to implement the best practices discussed in this study (e.g., IPA-to-provider communication strategy, number of high volume providers in a network, and the IPA revenue model by which payments to the IPA are processed). If any of these features is not optimal in a particular organization, it might constitute a barrier.
practices in their own environment to share strategies they have used to overcome these barriers within their learning collaborative. Engaging a coalition that has members from IPAs that have successfully implemented these best practices, and who are willing to share those experiences within a collaborative, will help to remove barriers to implementation.
Generate short-term wins. Short-term wins let the team know they are .making progress; it is both motiving and rewarding. Dr. Kotter believes this step highlights the importance of tracking progress both early and often.
The IPA community should celebrate and share small wins. An example is an initial decrease in readmission rates and improved health outcomes (such as HbA1C) resulting from applying best practices. Teams should be rewarded for achieving these short-term goals; doing so can create momentum and motivation in achieving longer term goals, such as sustained reduction in inpatient utilization across populations. The APG magazine which is distributed to a variety of stakeholders (including a large number of IPA organizations) can be used to share which best practices being implemented among willing IPAs and the results from those implementation efforts—including short-term successes (e.g., public recognition from large associations, such as APG.) These organizations may profiled in the newsletter and/or recognized at annual APG conference awards ceremonies. Some organizations may be reluctant to share their progress and how they achieved their wins with the wider IPA
community; however, a coalition of IPA leaders willing to share successes will help to establish a culture of intercommunity trust and cross-pollination of ideas. The IPA
community as a whole should celebrate the adoption of value-based care, and specifically of sharing success in applying evidenced based best practices.
Sustain acceleration. Quick changes and early successes can slow progress over the long-term. The seventh step in Kotter’s change model promotes sustaining change to stay the course and achieve the overarching vision. The goal of this step is to ensure that the
excitement for change and sense of urgency in the beginning do not fade.
Consistent momentum will need to be cultivated by requiring intra-community support from other IPAs. The coalition and volunteer army will work to set up regular (at least annual) learning collaborative gatherings for IPAs applying the best practices and incorporate measures to gauge progress and assess continual performance improvement. The gatherings will also aim to include IPAs wanting to learn more about best practices. The coalition (and volunteer army) will be charged with sustaining this initiative over time. As I deliver lectures to the APG community, I plan to (with permission) share the collective of experience of IPAs that have implemented best practices within their organization. This will help organizations recognize that other IPAs are moving towards an evidenced-based care approach in managing their complex populations.
The IPA community that forms should retain responsibility for policing their own progress, ensure accountability among the organizations, and consistently encourage engagement over time. It is strongly suggested that those IPAs implementing best practices share their progress via publications, conferences, seminars, webinars, and social media with the goal of illustrating the value of implementing the best practices to other IPAs. As
discussed previously, APG will be a major resource to catalyze the dissemination of these materials—using the coalition as the driving force for accomplishing these goals.
in the organization. For this to happen, organizations will need continuing to be positive reinforcement for employing these practices successfully over time. Positive reinforcement may including: publicity, monetary rewards, or peer recognitions; organizations may even be rewarded by health plans and government payers through additional perks such as improved contract deals, or membership to a preferred IPA. I will continue to work regularly with best practice champions, and the coalition and volunteer army to publicize the work of the IPA community implementing best practices through published articles, lectures, expert forums and involvement in associations such as APG. This will help to perpetuate the momentum established from the sense of urgency and quick wins. Once best practices are rooted in organizational operations, external rewards may be less necessary as the value from the best practices will begin to reap benefits within each organization –such as lowered costs from a reduction in inpatient utilization.
Diffusion of Innovation Theory
As discussed previously, Diffusion of Innovation Theory describes attributes
associated with the dissemination of innovation over time, and these attributes are thought to facilitate adoption. These attributes are: relative advantage, compatibility with existing values and practices, simplicity and ease of use, trialability and observable results. Below I will describe how these attributes are enhanced by the plan for change presented above.
Relative advantage. Refers to the degree to which an innovation is perceived as better than the status quo. The best practices described have been developed specifically to confer relative advantages for patients (improved health outcomes) and/or payers (lower costs) compared to existing practices. These relative advantages will be communicated to potential adopters as a central component of the plan for change, including publications,
lectures, newsletters, and experts and learning collaboratives to espouse these benefits to others in the IPA community.
Compatibility with existing values and practices. This step relates to how well the innovation fits within in the existing environment. Noting the volume-to-value movement in healthcare, best practices that are intended to increase total value delivered to the system will align very nicely with the recent shifts in the healthcare ecosystem to move towards
performance-based metrics. The level of compatibility of best practices with existing values and practices may differ from organization to organization depending upon that IPAs’ willingness to move to a value-based system; however, as an industry, compatibility should be high.
Simplicity and ease of use. This refers to the simplicity of the innovation and how easy it is to apply in practice. This perception of this attribute, like the prior attribute, will tend to vary across organizations due to differences in available resources and prior experience. The steps outlined above using Kotter’s change model are intended to communicate helpful strategies, and to develop learning collaboratives, which should enhance simplicity and ease of use.
Trialability. Trialablilty is the extent to which an innovation can be tested. This is the purpose of the learning collaborative sharing early results (and wins) amongst the IPA
community. The best practices are highly trialable, and this attribute will work to establish an increased measure of credibility and ideally confidence in those contemplating best practice implementation in their respective organizations.
observed when organizations improve health outcomes and reduce inpatient utilization. This can be accomplished through lectures, forums, panels, and learning collaboratives in which the results are shared consistently across organizations. The five attributes of the Diffusion of Innovation theory are readily enhanced by using Kotter’s 8-steps in the plan for change and